(rev. Aug. 2014)
APPLICATION FOR REGISTRATION,
RENEWAL OR CANCELLATION OF
FOREIGN CORPORATION NAME
Business Corporation Act
Secretary of State
Department of Business Services
501 S. Second St., Rm. 350
Springfield, IL 62756
Payment must be made by check or money
order payable to Secretary of State.
Filing fee $ _________________________ File # ___________________________ Approved: _________________
———— Submit in duplicate ———— Type or Print clearly in black ink ———— Do not write above this line ————
11. Corporation Name: ______________________________________________________________________________
12. State or Country of Incorporation: __________________________________________________________________
13. Date of Incorporation: ____________________________________________________________________________
14. Business in which Corporation is engaged: ___________________________________________________________
15. Post Office Address of Corporation to which the Secretary of State may mail notices:
16. The corporation desires to register its corporate name pursuant to Section 4.25, and it is not transacting business in
the State of Illinois at this time.
17. Attached to this application is a certificate setting forth that the corporation is in good standing under the laws of the
state or country wherein it is organized, executed by the proper officer of the state or country wherein it is organized,
and which certificate shall not be more than 90 days old.
18. Check appropriate box:
$50 registration fee
$50 renewal fee
$25 cancellation fee
19. Such registration or renewal of registration is effective from the date of filing by the Secretary of State until the first day
of the 12th month following such date.
10. Cancellation is effective upon filing with the Secretary of State.
11. The undersigned corporation has caused this statement to be signed by a duly authorized officer who affirms, under
penalties of perjury, that the facts stated herein are true and correct.
Dated _______________________________ , _____
Month & Day
Exact Name of Corporation
Any Authorized Officer’s Signature
Name and Title (type or print)
Printed by authority of the State of Illinois. January 2015 — 1 — C 197.11